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i <br /> � <br /> • " ! City of arano <br /> Building Permit A plication #ar Maintenanc� I Renavation <br /> : (win� ws, daors, siding, re-roo#, etc.) <br /> M�fll Address: Permit number: �C' � � - C�� ��,�� <br /> ,��� ; �_Ip Box 66 <br /> O � I 4rystal Bay,MN 55323-flD68 Dste received: c � � <br /> I Recsived by: <br /> � a Str'e�t Address: <br /> � o� ; �{`/�0 Kelley l�arkway Plan review fee: r�- <br /> ' dmno,MN 5535fi <br /> �'�x� I Total Fee: LE�' ,�_�/ <br /> Main: 952-249-4800 FBx- 52-249�616 vv�w ci rono.mn.u& ' <br /> This application i�orm must b�compfeted in full and al1 required informatlon must be submltted. <br /> lncomp�s�e applications wIN be retium�d. (Please pr�nt) <br /> G�NERAL 1NFORMA7lON: �� � <br /> Job Site/�lddress: ' ' <br /> WIl!this be a Par�de of Homes, Remad iers Showcase Hom�or otheC D�spfsy Home? Yes No, <br /> 1f yes,a special eV9nt permi#rs�pvlrod wifh Ro Jce Departm�nt and Ci(y Councif approVa/6Q days pr/or to the�Vent, Shtittl6 bus seNiCe wl!!bs <br /> required unless applicanY demonstr�tes sufilcient on,sfte parhing/s available. IJon-permitted evenfs tin+Nl n4t 6E aUowed. <br /> CONTRACTOR 1 APPLICANT IN�ORMAITION: <br /> Name: �+c1��o.\ �'��'� <br /> State License# �C,13Dq$"� li Expiration C7ate_ '?5 ('3 <br /> Lead Certificatlon tVumber' j� .-�,���S� - Expiration�ate: y <br /> (fvr worir on homes that were constru d prior fa 99�'8 ������ <br /> phane: (�S�-^ a'� -'��C)�'� �c ri (office} <br /> Mailing Address: 1�� , j� �� „ W�S-� C��Y= v�11� Z1P: SS l �3 <br /> Cont�ct Persort: Applicant is: ontra r ! Homeowner �c��is ano) <br /> Emalf snd/or Fax' <br /> � <br /> PROPERTY OWNER iN�ORMATION: ' I <br /> Name: � ��0�: . <br /> Phone(day): '�."' � �'4l� <br /> Address: "-� City: ZfP: <br /> Email and/or F�x <br /> PRO.f�CT INFORI1AATiQN: <br /> Type of ProJect: Any earth moverrsent may require <br /> MCWD review�petmits: <br /> ❑Door(s) I� Remadel ❑Fire Damage Minn9haha Creek Wstershed i7istrict(MCWD) <br /> ❑ft�roof,asphalt ❑Repa[r ❑Storm Damag� 18202 Mlnnetonka Bivd <br /> � D�ephaven, MN �5381 <br /> [�Re-roof,cedar ❑Restoration' []Water Damage �,����: g��.47�_p�gp <br /> Q R�roof,other{9pgciiy} ❑Sid':ng ' 0 Other. (specify) Fax: 852-471-0682 <br /> www.mint��hahacreek.or� <br /> �]Window(sj . "" — <br /> pveralf ProJect Descrip#ion: "�u:. S � �f P �a d`��S '� `5 � <br /> Estimated Construction Va[uation of R oject(ex�lud[ng I�nd) $ ` <br /> APPLICANT AGKNOW�EDGEIIIlEN : <br /> . Agl'ees to prOvfde af1 infotmation req'ired or reqUested by the Bttilding DegBrtmant; <br /> • Certffiss that the infomtatlort supplie Is true and co�on b�In awa�9�that ukoll f�lure t d0 So,tlhe St&ff has n�a�It6i'nafve <br /> are soEe{y responsible for submitting,a compfete 2pp 9 P <br /> but to reject lt unti!ft is camplete; <br /> . S9me or ali of the Infarmation that l�'ou are asked tp provide on thls appliCetlon is olassified by Staie !aw as either prtvate or <br /> confidenttal. Priv2te data is infarmation whioh generglly cannot be given to the public but can be given to the subject of the <br /> data. Conftdential tiata is inforrt�� n whiCh gener�Ily cannot be gfven to elther the publlc or the Subject of the dai�. Our <br /> purpose and Infended use of this in ormatior� is to annu�lty update our records and records of ather govem►nental aganCies <br /> n? uire�d b law. If ou refuse to su I fhe informstion,fhe a fication ma not l�e issued. <br /> Apolicant's Sianature: �� Date: ��� 1 � <br />